Power of the placebo antidepressant pill

Sarah Vine describes her history of being prescribed antidepressants and then having withdrawal problems (see Daily Mail article). She explains that antidepressants, in her view, stop the “metaphorical house falling down while you get the metaphorical builders in”. 

Not sure whether the pandemic has really increased antidepressant prescribing (see Lancet Psychiatry letter). The issue about efficacy of antidepressants has not really progressed since NICE produced its first depression guideline (see eletter: What does it mean to say that antidepressants have helped millions of people round the world?). The Critical Psychiatry Network (of which I’m a founding member) had a debate about this issue in 2003 (see another eletter). There is a genuine issue about bias in clinical trials of antidepressants (see yet another eletter). 

All this was looked at in a BMJ editorial in 2004 (see another eletter). The central issue is whether antidepressant trials hide amplified placebo effects and more recent research has not really taken this issue forward (see previous post). Antidepressants may not work any better than placebo. If this is true (which I think it may well be), it would have extraordinary implications for clinical practice. So-called antidepressant efficacy may merely be due to the placebo effect (see eg. my article).

Engaging people in Mental Health Act reform

Reform of the Mental Health Act in England and Wales can learn from reform in other parts of the world, not least Scotland (see previous post) and Italy (see another previous post). I'm also impressed with what the Victoria state government in Australia is doing (see its Mental Health and Wellbeing Act: update and engagement paper). 

The Royal Commission into Victoria's Mental Health System had a vision of a more holistic mental health system, rather than a system that often focuses on a ‘biomedical model’ of treatment and decision making. Treatment, care and support recommendations were about ensuring compulsory treatment is only used as a last resort; moving away from coercive practices; reducing the use of seclusion and restraint with the aim of elimination over a 10-year period; and regulation of chemical restraint (see final report). 

The Victorian Government is doing what I wished the UK government had done in England and Wales (see previous post) by repealing its current Mental Health Act and enacting a new Mental Health and Wellbeing Act. People living with mental illness or psychological distress will be provided with compulsory treatment only as a last resort after all other treatment and non-treatment options have been considered and excluded, and only when needed to prevent serious and imminent harm to themselves or another person (see eg. previous post for comparison of objectives in England and Wales which are much weaker).

There is already a right to a second psychiatric opinion in Victoria and the changes are designed to stop delays by making access to a second opinion more flexible. Reasons for not accepting the opinion of the second psychiatrist will need to be documented and, if necessary, the patient has a right to seek review from the Chief Psychiatrist or to apply to the Mental Health Tribunal for their order to be revoked. I have been arguing for detained patients in England and Wales to have a right to a second opinion, not only on medical but also nursing and social matters (see previous post). This would mean that Second Opinion Approved Doctors could be abolished, as applications can be made about treatment decisions to the Tribunal if needed, and it’s better that the patient is able to choose who provides the second opinion.

Similarly, I think the changes proposed to advocacy in Victoria have helpful implications for reform in England and Wales (see eg. last post). An opt out non-legal advocacy system will be created (see another previous post). Service providers will be required to notify non-legal advocacy services within 24 hours of the making of an order. No restrictions can be placed on the patient’s right to communicate with an advocate. The rights of the advocate to access records and obtain information will also be improved. These matters also need to be taken forward in introducing opt out advocacy in England and Wales.

Although the Independent review in England and Wales was motivated to improve the dignity and respect of detained patients (see previous post) , the Victorian government seems to be dealing with these issues better. It’s not too late to clarify the principles of Mental Health Act reform in England and Wales (see eg. another previous post) with implications for implementation of a new Bill.

(With thanks to Stephen Hinchley at Voiceability for alerting me to the work in Victoria)

Mental health advocacy is not just about IMHAs

The 2007 amendments to the Mental Health Act (MHA) in England and Wales introduced Independent Mental Health Advocates (IMHAs). As the Code of Practice makes clear, IMHAs may, if appropriate, help detained patients to exercise their rights by assisting patients to access legal advice and supporting patients at Tribunal hearings. I’m not convinced this happens as much as it should, and in practice IMHAs tend to regard legal advice and Tribunals as a separate process. Their role may include helping patients to seek advice from a lawyer, but once this has happened the lawyer is expected to take over responsibilities. IMHAs generally concentrate on helping patients with their care plan and if necessary supporting them in care plan review meetings.

The government plans to improve the quality of IMHA services in its MHA reforms (see eg. previous post). I think one way of improving that quality would be for IMHAs to have more integrated relationships with mental health lawyers and independent experts. A proper advocacy service should be seen as made up of IMHAs, mental health lawyers and independent experts. I think this more complete way of viewing advocacy services is even more important as the government also says it wants to expand Tribunal powers to treatment as well as detention decisions. The Responsible Clinician may be required by the Tribunal to reconsider particular aspects of the care plan and the suggestion is that the IMHA can challenge a specific treatment decision on behalf of a patient that lacks the relevant capacity.

Personally I would prefer if the government created a national mental health advocacy service but I am realistic enough to know that politically this is unlikely to happen. I suspect responsibilities will be left to local authorities to commission mental health advocacy services. What I would like to see is an expectation that commissioners purchase the more complete advocacy service I have been suggesting. Providers will have to build up relationships with mental health lawyers and independent experts, who could continue to be funded through legal aid.

I think implementation work leading to a new MHA Reform Bill should look at the commissioning of more compete advocacy services rather than just IMHAs. As I've said before (eg. see previous post), there seems to me to be considerable work to do before a new Bill is put before parliament.